LIFE INSURANCE

Aditya Birla Sun Life Insurance Company Ltd. PROTECTING INVESTING FINANCING ADVISING

DECLARATION OF GOOD HEALTH CUM MEMBERSHIP FORM

IMPORTANT NOTE: Any additional text written or qualification given in the form would make it invalid.

Name of the Policy Holder: C E N T R A L B A N K O F I N D I A

Policy Number: 5 0 4 9 3 6 / 5 0 4 9 3 7 Plan Option: P R E M I E R

Product Name (Scheme NO): A B S L I G R O U P A S S E T A S S U R E P L A N

Product UIN No: 1 0 9 N 0 4 5 V 0 2 Branch Code:

Branch Email ID: Branch Location:

Coverage Type: V a r i a b l e S u m A s s u r e d

Payment Mode: S i n g l e P a y

1. Particulars of the Life Assured

Mr. / Ms: ( F u l l N a m e )

Address of the Borrower:

Date of Birth: D D M M Y Y Y Y Gender: M F Contact No:

Email ID: Nationality:

Customer ID: Loan Account No:

Loan Disbursement Date: Loan/Policy Tenure:

Course Period: Cover Amount Opted for (Rs):

Loan Amount (Rs): Single Premium Amount( Incl GST):

2. Nominee Details

Nominee Name:

Relationship with Life to be Insured: Nominee DOB:

*Nominee needs to be a major i.e. above 18 years of age and should be one of the following: Husband, Wife, Son, Daughter, Father, Mother, Brother, Sister, Grandfather or Grandmother.
* Incase of Nominee being a Proprietor/Partnership Firm/Limited Company the above condition would not apply.

3. PROPOSER DETAILS (IF MEMBER INSURED IS MINOR)

Name:

Relationship to Life to be Insured:

4. Declaration of Good Health

I hereby declare that :

Place: ______________ Date: _______________

1. I am in good health.
2. I perform all my routine activities independently.
I declare that these statements are true

________________________________
Signature / Right Thumb impressions

3. I have never had any physical defect, deformity or disability affecting my day to day activities.
4. I have never suffered and am not currently suffering from:
a. High Blood Pressure, Heart Attack or any other Heart Disease;
of life to be insured

b. Stroke, Paralysis in any form, or any other Cerebrovascular Disease;

c. Diabetes or any other Endocrinal Disease, Kidney Disease;
d. Any Chronic Liver Disease;
e. Any Lung Disease (e.g. Chronic Obstructive Pulmonary Diseases, Parenchymal lung Disease, Pulmonary Embolism etc).
f. Blood Disorders, Gastro-Intestinal Diseases, Paraplegia or any other disorder of the bones, spine or muscle;
g. Any Cancer or Cancerous growth;
h. Any Mental or Psychiatric condition, any Genetic Disease or any disease related to central nervous system (disease related to brain);
i. HIV / AIDS or AIDS related complications.
5. I have never been asked by our family doctor or any physician to reduce my weight or change my smoking (tobacco use in any form) or alcohol intake
6. I have never been absent from work due to any illness or injury for a continuous period of more than 7 days during the last two years
7. I have never undergone nor have I been advised to undergo any major surgical procedure.
8. In the last 2 years, I have not –
a. been continuously hospitalised for more than 7 days (other than fractures of leg or arm);
b. undergone any investigations (including basic radiological and blood tests) other than normal Health Check-ups and Insurance Medicals, or
c. had adverse result for any blood tests, X-Rays, ECG, Stress Test, Biopsies, CT Scan, MRI, Ultrasonography or 2D / 3D Echo etc.
9. I have not had any proposal and / or policy for life, health, accident or critical illness or any other riders, including simultaneous / renewals / revivals therefore, declined,
deferred, withdrawn or accepted at extra premium or reduced cover or offered any special terms by any insurance company.
10. I have not had any member of my immediate family e.g. parents, brothers, sisters, suffered from heart disease, stroke, cancer, kidney failure, organ transplant or any other
chronic or hereditary conditions before the age of 60 yrs.
11. I do not engage or intend to engage in any business, sport or occupation or any hobby of a hazardous nature.
*Disability means inability to function normally, physically or mentally
12. If answers to the above health declaration is NO, please provide the details below:
___________________________________________________________________________________

I further declare that the above statements are true and complete in every respect related to my health and will form the basis of granting insurance cover to me, from Aditya Birla
Sun life Insurance Company Limited.[ABSLI]. I further hereby agree and give my consent to, the Policy holder for use of the contents of this Declaration by ABSLI for examining and
processing any claim arising, in respect of the insurance cover that may be provided to me under the referred group policy. I hereby confirm that my intent to participate in the above
plan for the Policyholder's customers is purely on a voluntary basis, and have further understood the terms and conditions of life insurance cover that maybe extended to me. I
confirm and agree that the insurance cover, if provided, will be governed by the provisions of the Insurance Act, 1938 and the Policy Contract under which the cover will be offered
to me. I agree and understand that if I contract any of the above diseases between submitting this document and the date of commencement of the cover, I shall not be covered
under the policy. I have also not withheld any material information or suppressed any fact. I undertake to notify ABSLI ('The Company”) of any change in my state of health or
occupation or any decisions subsequent to the signing of this declaration form and before the acceptance of the risk by the Company. I understand and agree that if any untrue
statement be contained herein, I, my heirs, executors, administrators or assignees shall not be entitled to receive any benefits which may be provided to me on the faith of this
declaration, including, inter alia the aforesaid insurance cover.
I understand and acknowledge that insurance cover shall be as per terms and conditions detailed in the Policy Contract issued by ABSLI in favour of the Policyholder and that ABSLI's
decision in respect of all aspects of the referred group life insurance plan shall be final & binding. I hereby agree to and authorize the Policyholder / my Doctor / Hospital / Local,
State, Central authority / Dealer / Distributor /my Employer to divulge or convey any information or particulars relevant to this Form / my admission into the referred Group
Insurance Policy to ABSLI at any point during the continuance of my cover hereunder including any claim under the said Policy. I authorize that my personal information may be
provided to ABSLI by any medical practitioner, hospital and clinic, employer, institution, or any person or persons that may have any and all information about my health, medical
history, and any hospitalization, advice, diagnosis, treatment, disease or ailment. I also consent to a personal investigation as part of this Health Declaration. I also permit ABSLI to
approach me directly for any clarification and / or other purposes. I hereby authorize Central Bank of India. (Master Policyholder) to receive all such monies payable by Aditya Birla
Sun Life Insurance Company Ltd. to the extent of my outstanding loan amount in the event of my death and the balance if any to the appointed Nominee as mentioned above and
in the absence of the appointed nominee to my legal beneficiary as applicable.
I /We hereby agree that terms and conditions including premium and the benefits payable under the policy are subject to variation in accordance with applicable laws
All material facts, being facts, which may influence as the assessment of this risk, have been disclosed in this Health Declaration, it being understood by me that failure to make
such disclosure renders the contract voidable at the option of ABSLI. I understand that Insurance is a contract made in utmost good faith trusting the proposer and life assured to
disclose all relevant (material) facts, in response to questions in the form.

I hereby provide my consent to receive call from Aditya Birla Sun Life Insurance Company Limited (ABSLI) or its authorized Service Providers in connection with any matter related to my above Policy.

DECLARATION WHERE SCRIBE IS INVOLVED (COMPULSORY FOR ALL DECLARATIONS SIGNED IN ANY VERNACULAR LANGUAGE)

I ___________ ______________________________________ (full name of scribe) have explained to the borrower the contents of this form in his own language and he/ she has fully
understood the same. Also, I have explained that if any untrue statement is contained herein, the borrower, and/or the heirs, executors, administrators, assignees of the borrower shall
not be entitled to receive any benefits, including, inter alia, benefits under any insurance policy procured on the faith of this Form.

Place: _________________ Date: __________________ Signature of the Scribe: _____________________

Place: _________________ Date: __________________ Witness Signature: _________________________

Section 41 of the Insurance Act, 1938:

1) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew or continue an insurance in respect of any kind of risk relating
to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing
or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer. Provided that acceptance by an
insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within
the meaning of this sub section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed
by the insurer.
2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to ten lakh rupees.
Fraud and Misrepresentation
As per the provisions of Section 45 of the Insurance Act, 1938 and amended from time to time. For more details on Section 45 of the Insurance Act, 1938 please refer to our web
site www.adityabirlasunlifeinsurance.com

Suicide:
I understand that for deaths due to suicide in the first year of coverage, only 80% of the premium paid is refunded and amount mentioned in Death Benefit Provision is not paid. I also
acknowledge that the cover is applicable to primary borrowers. In case of surrender of the coverage due to prepayment of entire loan or foreclosure of the savings by a member, a surrender
benefit may be payable under single premium or short pay mode, aer the second policy anniversary.
FOR/12/17-18/1308

Place: _________________ Date: __________________ Signature of the Borrower: ____________________

Place: _________________ Date: __________________ Witness Signature: _________________________

Aditya Birla Sun Life Insurance Company Ltd. (ABSLI) formerly known as Birla Sun Life Insurance Company Limited.
Registered Address: One Indiabulls Centre, Tower 1, 16th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road,
Mumbai - 400 013 | +91 22 3996 1000 CIN: U99999MH2000PLC128110. IRDAI Registration No. 109. Contact Us:
care.lifeinsurance@adityabirlacapital.com | www.adityabirlasunlifeinsurance.com 1-800-270-7000
“The Trade Logo “Aditya Birla Capital” Displayed Above Is Owned By ADITYA BIRLA MANAGEMENT CORPORATION PRIVATE LIMITED adityabirlacapital.com
(Trademark Owner) And Used By ADITYA BIRLA SUN LIFE INSURANCE COMPANY LIMITED (ABSLI) under the License.”